Overlay
Map Gallery

Map Request Form

Contact Information
Name:


Location to patrol (address, Apt #, etc.):


City:


State:


Zip:


Home Phone Number:


Cell Phone Number:


Email Address:


Schedule Information

Start Date (mm/dd/yy):


End Date (mm/dd/yy):


Security Alarm System

Do you have a security alarm system installed?                           Yes      No

If yes, is your alarm system monitored by a monitoring service?           Yes       No

If yes, what is the name of the monitoring company?                                   

Lighting Information

Will there be lights on at the location?                                 Yes       No

If yes, location of lights to be on (ex: porch, left window, driveway, etc.):  

Will any outside lights be actived by motion detectors?                              Yes        No

Vehicles

Will there by any vehicle(s) left at the location in sight?                              Yes         No

If yes, complete the following vehicle information:
Vehicle #1 Description (make, model, color, license, location):              

Vehicle #2 Description (make, model, color, license, location):              

Access

Will anyone have access (key) to the location while you are away?         Yes           No

Name:                                                                                                                                     

Phone Number:                                                                                                                 

Will anyone be at the location while you are away (cleaning person, checking mail, feeding animals)?                 Yes          No

Name:                                                                                                                                     

Phone Number:                                                                                                                 

Miscellaneous Information                                                                                        

Hold Harmless
Winfield Police Department, as per your request, will periodically check your location listed above. By clicking the "SUBMIT" button it is understood and agreed that neither the Winfield Police Department or City of Winfield assumes any liability with the Vacation Check Program.